A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?

Position the client prone and have the respiratory therapist perform postural drainage.

Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.

Increase oxygen to 70%.

Switch oxygen to a nonrebreather mask.

Answer and Explanation

The Correct Answer is B

A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.

B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).

C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.

D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Measure the depth and width of the wound. Regular assessment and documentation of the wound’s size can help track the progress of healing and effectiveness of the treatment plan.

B. Educate the client about the need for antibiotics. If an infection is present, antibiotics may be necessary. It’s important for the client to understand the purpose and proper use of these medications.

C. Consult a nutritionist for a diet plan. Good nutrition is essential for wound healing. Certain nutrients, like protein, vitamin C, and zinc, can promote wound healing.

D. Remove any non-viable tissue. Debridement, or the removal of dead (non-viable) tissue, can help promote the healing of the wound by reducing the risk of infection and allowing healthy tissue to grow.

A. Infection B. Malnutrition C. Continued pressure D. Venous insufficiency

Correct Answer is B

Explanation

A. Infection: While infection can certainly delay wound healing and contribute to the development of chronic wounds, it is more of a local factor rather than a systemic cause. Infections can hinder the normal healing process and lead to tissue damage, inflammation, and prolonged wound healing.

B. Malnutrition

A chronic wound is a wound that fails to progress through the normal stages of healing in an orderly and timely manner. Systemic factors can significantly impact wound healing, and malnutrition is one such systemic cause. Malnutrition, which refers to an inadequate intake or absorption of nutrients essential for healing, can impair the body's ability to repair tissues, fight infection, and generate new cells.

C. Continued pressure: Prolonged pressure, such as that experienced in pressure ulcers, can lead to tissue ischemia (lack of blood flow) and tissue necrosis, resulting in chronic wounds. However, this is considered a local factor related to the specific site of the wound and pressure-related damage.

D. Venous insufficiency: Venous insufficiency can cause chronic wounds, particularly venous ulcers, due to impaired venous return leading to increased pressure in the veins of the lower extremities. This pressure can result in tissue damage and poor wound healing. While venous insufficiency is a systemic condition, it primarily affects specific areas of the body (such as the lower legs) and is more directly related to the development of localized chronic wounds in those areas.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chronic wound. Which of the following are wound treatments that may assist with the healing process?

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

Correct Answer is B

Explanation

A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

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